The invention relates to a method of automatic guiding a C-arm X-ray device according to the concept of claim 1.
A C-arm X-ray device (in the following called C-arm) is used routinely today for the intraoperative control of length and axial and rotational alignment of bones or bone fragments in osteosynthesis. In order to point out the task of the method according to the invention the step xe2x80x9cintraoperative imagingxe2x80x9d is described as technical regulatory process in the following section.
In conventional, open operative technique the surgeon receives his visual feedback partly via direct vision without radiography. Therefore, a separate operative step xe2x80x98intraoperative imagingxe2x80x99 cannot be delineated. In order to obtain a particular view of a fracture, the surgeon may have to alter his own position relative to the patient or the position of the retractor on the patient. The desired view of the fracture corresponds to the target value and the patient can be identified as the controlled system. The surgeon records with his eye (measuring unit) the current view of the fracture and compares it with the desired view. From the difference (control deviation), the surgeon (controller) determines, on the basis of his experience, the type and extent of the necessary positional alteration. As a result the surgeon achieves a new view of the fracture which is expressed in regulatory terms as the actual value. In a block diagram, this situation may be expressed as a simple control circuit with only three elements. An optimal regulatory behavior is achieved on the basis of direct visual feedback and a simple control circuit. This model can be applied to the description of soft tissue interventions and of those open osteosynthesis procedures at which the C-arm is not used.
If the surgeon obtains his visual feedback by intraoperative imaging with the C-arm, then intraoperative imaging can be delineated as an individual operative stage. This will be expressed in the following as a technical regulatory process for the constellation intraoperative imaging with the C-arm and image guidance with the combination C-arm/surgical navigation system.
For this constellation the external C-arm operator and the C-arm as a device must be taken into account as well as the patient and the surgeon in order to be expressed in regulatory terms. The representation in a block diagram therefore requires additional elements. The intraoperative positioning procedure can be described as a serial connection of one outer and one inner control circuit.
The outer control circuit includes all persons and appliances participating in the process, i.e. the surgeon, the C-arm operator, the patient, and the C-arm. Adjustment to the desired projection, in other words, the target value, is regulated by the outer control circuit. The current projection (actual value) is shown on the monitor of the image intensifier. The surgeon (controller) compares the desired and the current projection.
A projection is defined by the orientation of the rays relative to the object being imaged. For any desired projection, the C-arm must therefore take up a specific position relative to the imaged fragment. The surgeon can only tell his description of the desired position in somewhat inexact terms and this depends upon his experience (interpreter). He communicates the position to the C-arm operator. The operator of the C-arm, the patient and the C-arm correspond to the outer control circuit as the controlled system which the surgeon influences as controller.
On the other hand, the interaction between the operator of the C-arm, the patient and the C-arm can be described as a second, inner control circuit with which the correct position of the C-arm is achieved. The operator tries to move the C-arm to the position stipulated by the surgeon. The C-arm operator acts as a controller in that he compares the position stipulated by the surgeon (target value) with the existing position of the C-arm (actual value). On the basis of his experience (interpreter), he plans suitable corrective movements. These may or may not be possible due to circumstances such as limited space or concerns for sterility (=disturbance factors). The actual position is constantly registered by the C-arm operator by eye (measuring unit), i.e. he receives continuous direct visual feedback. Only when the operator is satisfied with the position of the C-arm and the regulatory process in the inner control circuit is completed does the surgeon receive his first, delayed, visual radiographic feedback (measuring unit C-arm). Before the desired projection appears on the screen, the above procedure may have to be repeated several times.
The entire process has to be repeated in the same manner in order to reproduce a projection.
Surgical navigation systems make possible continuous image guidance based on stored data. This is done by representing the spatial relationships between surgical instruments and anatomical objects of interest on the screen. A surgical navigation system includes a facility for recording the position of the instruments in the operation room as well as the software and corresponding hardware components. This operates on a transceiver principle: on each surgical instrument transmitters tuned to the receivers are permanently mounted. Their position in the operating theater tracked by the receiver and positional information transmitted to the navigation system. Before each application of the surgical navigation system digital images of the patient are copied from an imaging unit (CT, C-arm) to the navigation system. The positional data on surgical instruments and anatomical objects in the OR make it possible to generate a simulated projection of the current position of the instruments on the recorded digital images.
The combination of surgical navigation system and C-arm can be applied during trauma surgery in the modes xe2x80x9cpositioning of the C-armxe2x80x9d and xe2x80x9cimage guidancexe2x80x9d. In the xe2x80x9cpositioningxe2x80x9d mode the navigation system helps the surgeon to place the C-arm correctly for a previously defined projection. To do this, the relative position of the C-arm with which the desired projection will be achieved and the object to be imaged (implant or fragment) are stored in the navigation system. lntraoperatively, the actual positions of C-arm and object to be imaged are tracked and from them the relative positions are calculated. Consequently, the target and the actual relative positions are imaged on the monitor of the navigation system.
To express this situation in terms of automated control engineering, the navigation system has to be taken into account. In the xe2x80x98positioningxe2x80x99 mode, it functions to set the target value for the surgeon. He can thus give more exact positional commands to the external operator of the C-arm. The navigation system is however not linked into the inner control circuit with which the positioning of the C-arm is controlled.
Even in this configuration the total process must be repeated as described if a previously set projection is to be reproduced.
In order to achieve an optimal handling procedure, the surgeon must be able to alter the position of the C-arm - and thus the visible imagexe2x80x94independently and immediately. This requirement is not fulfilled if a C-arm is used with the usual equipment available today for intraoperative imaging: the device is operated and positioned by a third person. This procedure takes time, is open to error, and leads to additional difficulties:
The entire procedure for setting up a projection has to be repeated if the projection needs to be reproduced, for example, when checking a reduction manoeuvre.
The radiographic checks necessary for positioning represent an additional exposure to radiation for the patient and the team in the operation room.
The person operating the C-arm has to be available more or less throughout the operation even though assistance may only be required occasionally after long waits.
These problems show clearly that an improved interface between the surgeon and the imaging unit must be found for intraoperative imaging with the C-arm. This becomes even more apparent at image-guided operations in which the surgeon is almost totally dependent on the information from images for the coordination of his manipulations.
On this point, the invention intends to provide remedial measures. The invention is based on the objective of providing a method of using a C-arm X-ray device that is automatically guideable by means of automatic controlling means.
The invention solves the posed problem with a method that displays the features of claim 1.
To execute the method according to the invention the C-arm X-ray device must be equipped with a motorized positioning unit apt to adjust the C-arm X-ray device in a desired position upon receiving control commands given by the C-arm operator, the surgeon (e.g. xe2x80x9cvoice controlxe2x80x9d) or by a computer assisted surgery system. Such a motorized exact positioning unit for a C-arm X-ray device (MEPUC) is disclosed in the International Patent Application No. PCT/CH00/00022.
The method according to the invention essentially comprises the steps of: A) attaching a first reference element at the bone or bone joint to be surgically treated in order to establish a measurable reference of the position and orientation of the bone or bone joint with respect to an on-site three-dimensional system of coordinates;
B) positioning the C-arm X-ray device in a desired position with a desired plane of projection at the bone or bone joint to be surgically treated. This first positioning may be effected manually through an assistant or by means of an control system which may be integrated in a Surgical navigation system;
C) measuring the position and orientation of a second reference element at the C-arm
X-ray device with respect to the on-site three-dimensional system of coordinates in order to determine the position of the C-arm X-ray device with respect to the on-site three-dimensional system of coordinates;
D) determining the position and orientation of the plane of projection with respect to the on-site systems of coordinates;
E) measuring the position and orientation of the first reference element at the bone or bone joint with respect to an on-site three-dimensional system of coordinates;
F) referencing the position and orientation of the plane of projection to the position and orientation of the first reference element in order to establish a mathematical relationship between the position and orientation of the plane of projection and the position and orientation of the bone or bone joint;
G) displacing the bone or bone joint in order to effect the desired surgical treatment at the bone or bone joint, whereby the surgical treatment may be e.g. a reduction manoeuvre;
H) measuring the actual position and orientation of the displaced bone or bone joint, whereby the actual position and orientation may be measured continuously during the surgical manoeuvre or subsequently;
I) determining the deviation between the actual position and orientation of the first reference element and the position and orientation of the first reference element referenced under step F);
K) determining the position of the C-arm X-ray device whereto the C-arm X-ray device has to be situated in order to reset the plane of projection as referenced under step F); and
L) guiding the C-arm X-ray device in the new position and adjust the plane of projection as determined under step K) by means of automatic controlling means.
The measurement of the position and orientation of the reference elements with respect to the three-dimensional on-site system of coordinates is performed with a position measurement device that is connected to the computer using software to evaluate the coordinates from the data received from the position measurement device.
The reference bodies preferably comprise at least three markers that are non-collinearly arranged. The markers as well as the detectors of the position measurement device may be acoustic or electromagnetic effective means such as energy emitting, receiving or reflecting means. For instance as energy emitting means:
Light sources, particularly light emitting diodes (LED""s );
Infrared light emitting diodes (IRED""s ); or
Acoustic transmitters
or as energy receiving means:
Photodiodes; or
Microphones
may be used. Other position measurement devices contain coils as energy emitting means and Hall-effect components as energy receiving means may be used as well.
A custom optoelectronic position measurement device may be used e.g. an OPTOTRAK 3020 System, Northern Digital, Waterloo, On., Canada. It preferably comprises
an OPTOTRAK 3020 Position Sensor consisting of three one-dimensional charge-coupled devices (CCD) paired with three lens cells and mounted on a stabilised bar. Within each of the three lens cells, light from an infrared marker is directed onto a CCD and measured. All three measurements together determinexe2x80x94in real timexe2x80x94the three-dimensional location of the marker;
a system control unit;
a computer interface card and cables;
data collection and display software; and
a strober and marker kit.
Computer assisted surgery systems (CAS systems) that are provided with a computer and a position measurement device in order to measure the position of surgical instruments or devices which are displaceable within the operation area are disclosed e.g. in U.S. Pat. No. 5,383,454 BUCHHOLZ and EP 0 359 773 SCHLONDxc3x96RFF. Often these CASxe2x80x94systems comprise a memory means in order to store medical images such as e.g. X-rays, Computertomographs or MR images (Magnetic Resonance images) using radiant energy means. Thereby the medical images may be gathered pre-operatively or intraoperatively.
Additional advantageous embodiments of the invention are characterized in the subclaims.
The advantages achieved by the invention are essentially to be seen in the fact that, thanks to the method according to the invention
shorter operation times;
reduced intraoperative radiation exposure; and
reduction of personnel necessary during the surgical operation may be achieved.